How to Avoid Medi-Cal Services Fraud

The unfortunate reality is that Medi-Cal fraud and abuse exists. It costs billions every year in diverted funds that could have been used for valid health care services. Because of this fraud and abuse, the cost of Medi-Cal has increased needlessly. Another problem is the risk of harm to patients who are unknowingly exposed to unnecessary medical procedures for the benefit of fraudulent doctors. Your Los Angeles Medi-Cal attorney can help you to recognize and avoid Medi-Cal services fraud.

What is considered Medi-Cal services fraud?

Medi-Cal fraud happens when someone intentionally misrepresents the truth in order to acquire unauthorized Medi-Cal benefits. As your Los Angeles Medi-Cal attorney knows, Medi-Cal services fraud is not only committed by patients. Healthcare providers can be guilty of Medi-Cal services fraud, as well.

Typical examples of Medi-Cal services fraud by patients

Patient fraud can take many forms. For instance, it is fraudulent to file a claim for services or products that are not actually received by the patient. Similarly, forging or altering receipts in order to be reimbursed by Medi-Cal is also fraud.

Obtaining medications or products that are not needed and then selling them on the black market is an egregious form of fraud. If a patient provides false information or uses someone else’s insurance to obtain services to which they are not entitled, that is also actionable fraud. Another very common type of patient fraud is “shopping” for doctors in order to obtain multiple prescriptions.

What you can do to avoid the appearance of Medi-Cal fraud

In order to avoid unknowingly committing fraud there are a few things you should not do. First, do not contact your doctor to request a service that you don’t need. Likewise, don’t let anyone persuade you to see a doctor for care or services you don’t need.

Common examples of provider fraud

Medi-Cal fraud is not limited to the actions of the patient, but can also be committed by health care service providers. Here are some common examples of that type of Medi-Cal fraud:

Billing for services not actually performed

Billing duplicate times for the same service

Falsifying a diagnosis

Billing for a more costly service than performed

Accepting kickbacks for patient referrals

Billing for a covered service when a non-covered service was provided

Ordering excessive or inappropriate tests

Prescribing medication that is not medically necessary

There are a few ways you can recognize this type of fraud. When you receive services from your health care providers, keep a record of the dates and save the receipts and statements you receive. You can then compare the dates and services on your calendar with the statements you receive from Medicare to make sure they are accurate.

Avoiding the appearance of fraudulent transfers in estate planning

A common misconception that clients have is that applying or qualifying Medi-Cal requires them to give away all of their property. Because of this misunderstanding, far too many clients attempt to simply transfer their assets to relatives in order to protect their eligibility. Unfortunately, this can be a big problem if it appears that you are hiding assets from Medi-Cal in order to qualify.

The 5-year look back period imposed by Medi-Cal law

In 2005, a law was passed that establishes an penalty period that applies to anyone who transfers their property within the five years prior to submitting their Medi-Cal application. The timing of any transfers you make is important because the period of eligibility starts when you submit your application. For that reason, ask your Los Angeles Medi-Cal attorney to help with your Medi-Cal planning.

How the Medi-Cal penalty period works

If a Medi-Cal applicant gives $5,000 of her estate to a family member four years and a half months before submitting her application, the period of ineligibility would begin when the application is submitted, not when the assets were transferred. The period of ineligibility is referred to as the “penalty period.” The length of the resulting penalty period will depend on the amount of the assets that were inappropriately transferred. With careful Medi-Cal planning, you can still retain control of your property while maintaining your eligibility for Medi-Cal benefits. The Medi-Cal penalty period is only applicable for long-term care expenses in an institutional setting, or for those receiving long-term home health care.

Download our FREE estate planning worksheet today! If you have questions regarding Medi-Cal planning needs, please contact the Schomer Law Group for a consultation, either online or by calling us at (310) 337-7696.

A graduate of Boston University School of Law, Scott P. Schomer is a frequent lecturer on estate planning and elder law issues, having discussed these important issues on local and national television. A seasoned courtroom advocate, Scott has obtained combined judgments and verdicts in excess of twenty-five million dollars for his clients. Scott has served as a member of the Los Angeles Superior Court Probate Volunteer Panel (PVP Attorney), Probate Settlement Panel and a Judge Pro Tempore. Scott's expertise has been recognized by his peers with such accolades as a life-time membership in the Multi-Million Dollar Advocates Forum, the Five Star Wealth Manager designation, and repeated nominations as California Super Lawyer.

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